Data Mining is Being Used for ZPICs Targeting Purposes

ZPIC Targeting

(November 16, 2011): Many providers believe that their practice is a normal one – average billings, average patient load, costs of care which are consistent with industry standards – and that they need not be concerned with undergoing a Medicare post payment audit for being a “statistical outlier.” As you may know, Medicare and Medicaid contractors rely heavily on “data mining” to identify potential audit targets. With data mining, Zone Program Integrity Contractors (ZPICs) and other program integrity contractors working for the Centers for Medicare and Medicaid Services (CMS) can look at historical billing data, as well as billing date from regional and local peers of a particular provider, and determine if that particular provider’s billings appear suspect.

I. What Role Does Data Mining Play in ZPIC Targeting?

While a provider might think its billing is in line with or below that of its peers, it is very important to remember that the Medicare post payment auditors are experts in “slicing and dicing” the data in so many ways that virtually every provider could show up as an outlier. For instance, perhaps the cost per patient, cost per procedure or cost per service plotted high, or maybe the total number of services per patient was high. For length-of-stay (LOS) providers, perhaps the total number of days of service on average was high or the billings per day ended up being high.

II. Are Your Coding Utilization Ratios Different Than Those of Your Peers?

Moreover, even if a provider thinks they run a “tight ship,” a lot of Medicare claim reimbursement is dictated by the medical necessity of the services provided to each patient. For instance, a provider may have a string of highly complex, highly demanding patients, who need more in-depth care. These same providers may have gained a local reputation for handling high complexity cases, thereby resulting in higher-than-average billing practices. When a program integrity conducts data mining, outliers will quickly be identified and targeted for audit. Today, ZPICs and other Medicare auditors are actively looking out for providers with aberrant billing practices and have many ways of interpreting the relevant information to justify their audit decisions.

Healthcare Attorney

Robert W. Liles, J.D., serves as Managing Partner at Liles Parker, Attorneys & Counselors at Law. Mr. Liles has extensive experience handling Medicare prepayment and postpayment audits and appeals. For more information or to speak to Mr. Liles, please call 1 (800) 475-1906 today for a free consultation.